Warren Buffett’s prostate cancer choices aren’t right for every man

A version of this column was published on April 24, 2012 in USA Today.

There has been a recent uptick of elderly men in my primary care clinic asking about prostate cancer, perhaps because they heard of Warren Buffett’s recent prostate cancer diagnosis and his proposed treatment.

Patients are wondering if they should also be screened. Other patients who already have been diagnosed are wondering if they should receive radiation treatment for their prostate cancer, as Buffett is planning to do. It is very important to remember that what’s right for Buffett may not be right for everyone else.

According to Buffett’s letter to shareholders, his prostate-specific antigen (PSA) had been “regularly checked for many years.” A sudden jump in his PSA level led to a prostate biopsy and cancer diagnosis. But should an 81-year-old man even be screened for prostate cancer?

The evidence says no. The U.S. Preventive Services Task Force, an independent panel of non-government clinicians providing data-based practice guidelines, recommends against prostate cancer screening for healthy men. Studies over the years, which have included participation of more than 300,000 men of various ages, have failed to show prostate cancer screening saves lives.

“If there is significant benefit, it should have been apparent by now, and it is not,” said Virginia Moyer, chair of the task force.

The guidelines of other organizations, which are not as stringent as those suggested by the task force, also question Buffett’s routine prostate cancer screening. For instance, the American Cancer Society and American Urological Association both recommend that doctors discuss the pros and cons of prostate cancer screening with men whose additional life expectancy exceeds 10 years. Even by that measure, screening Buffett — who can expect to live another eight years, based on actuarial data from the Social Security Administration — is questionable.

According to his letter, Buffett was diagnosed with Stage 1 prostate cancer, meaning the cancer had not spread beyond the prostate. The prognosis is generally excellent for this early-stage cancer, and for many men, just monitoring the cancer to ensure it doesn’t spread is proper. More aggressive treatments are available, including surgery and radiation therapy, which Buffett plans to undergo. The problem with these options is that the treatment may be worse than the disease.

The fact is, 75% of men over the age of 80 have cancer cells in their prostate, but in elderly men cancer grows so slowly that the men are much more likely to die of something else.

Moreover, for all men, prostate tests are not sophisticated enough to determine which of these cancers are dangerous and which are not. Without knowing, most men opt for treatment. But for every 1,000 men treated for prostate cancer, five will die of complications from surgery. Side effects of both SURGERY and radiation can include impotence, incontinence and frequent urination — all for a disease that, at Stage 1, has less than a 1% chance of causing death in the next 10 years.

The annual cost of PSA testing contributes $3 billion annually to health care spending, much of it paid for by Medicare and the Veterans Administration, without significant health benefits. In fact, Richard J. Ablin, the scientist who discovered PSA, calls its widespread use a “public health disaster.” Buffett’s high profile cancer coverage should have been an opportunity to educate the country that, for many, more conservative options would not only save them from harmful, unnecessary treatments, but also potentially reduce health costs.

Instead, some may view Buffett’s decision to screen for prostate cancer and aggressively treat it as the right thing to do. I’m not second-guessing the approach taken by Buffett and his medical team. And I also understand that some men would rather know their prostate cancer status and accept the risks of too much testing. but we should realize that Buffett’s prostate cancer path isn’t necessarily the right road for every man.

Comments are moderated before they are published. Please read the comment policy.

glasshospital

I’ll go ahead and second guess it, since he made the decision to broadcast this into the public domain.

Whether Buffett has it treated or not, he’ll eventually die from something else. Now he’ll just have complications of the treatment. Another example of auto-piloting a screening test–likely without the proper discussion. Who would dare NOT offer a billionaire such a “simple” screening test?

The problem is that people like my father see Buffet as a role model–in finance and now in medicine. If it’s good enough for Buffett, why shouldn’t a 75 year old in good health KEEP getting the PSA year after year, even though at this stage of his life it’s far more likely to do harm than good?

James deMaine

This is an example of the medical-industrial complex gone awry. Prostate CA is bread and butter for the Urologist, Radiation Oncologist, hospitals, diagnostic labs, imaging centers, robotic instrument manufacturers (“what, your hospital doesn’t have a Da Vinci robotic machine??”), sexual impotency centers, etc. Two recent patients I know of had serious complications: one was an incisional hernia where the robotic device had been inserted; one has incontinence and has subsequently had another operation to insert a pneumatic valve at the bladder outlet which he can trigger. I think patients like Mr. Buffet are sucked into the maelstrom of the technological imperative. Being rich doesn’t always get you the best non-treatment!

For true informed consent, I’d suggest an interactive computer assisted video program where the patient can ask, “OK, show me a patient with a good outcome” and up pops a video of a happy camper; then “OK, show me a patient with a bad outcome” and up pops the unhappy patient. Then, “OK, let me here both sides of the expert debate on the necessity of the PSA and/or treatment” – then the experts speak.

Actually a system like this has been devised for men with BPH, considering surgery. As might be expected, men given this full-throttle informed consent significantly put off surgery, being content to be monitored for their BPH symptoms.

Michael Wosnick

Very good article, except that I think you genuinely wimped out at the end by your equivocation. The fact that Mr.
Buffett was even having his PSA tested in the first place is already going against any
conventional wisdom for a man his age.
In an era where we have just had some solid recommendations of
medical tests that we ought not be overusing (see: Choosing Wisely: http://choosingwisely.org/?page_id=13) and http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Soc_Clin_Onc.pdf
) the fact that Mr. Buffet had an MRI, PET and/or CT scans etc as well
as PSA screening at the age of 81 is setting a very poor example indeed.
So, I cannot and will not condone his actions.
Having said that, there is one extraordinary circumstance here that
surely MUST have come into play, and it has nothing to do with medicine,
evidence or health policy. It is all about business and economics.
In Mr. Buffett’s position, there is no way a prostate cancer
diagnosis could have remained a secret. As one of the world’s richest
men, and leader of an investment giant that is perhaps unparalleled in
influence, I suspect that this was a business decision to preempt any
notion that he was not gong to be just fine, he was “taking care of
business” in his usual direct way, and that Berkshire Hathaway was going
to be just fine.
So, ironically, the very things that might have given him a golden
opportunity to be a powerful role model for doing the right thing
according to medical and health practice are the very reasons, I
suspect, why he felt he could not do so.
Pity….